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Tech Needs Assessment
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1.
What technology is your company developing?
(Required.)
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2.
What is the name of your company?
(Required.)
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3.
List the primary decision maker at your company.
(Required.)
Name:
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Company:
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Address:
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Address 2:
City/Town:
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State:
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AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP:
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Email Address:
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Phone Number:
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4.
Who holds the highest engineering or technical position at your company?
(Required.)
Name
Title
Education Level
Email
Phone
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5.
Where is your company incorporated and where is it's primary place of business?
(Required.)
New York, NY --> New York, NY
Other (please specify)
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6.
What do you need to grow?
(Required.)
Need training in basic entrepreneurial concepts.
Need access to investment community.
Need SBIR assistance.
Need help developing a prototyping and manufacturing strategy.
Want to get products to market faster.
Want access to a larger network of technologists and strategic partners.
Need help protecting my intellectual property.
Need help improving sustainability or 'greening' my products.
Other (please specify)
7.
What stage would you say your technology is in on the path to commercialization?
Concept / Thought / Idea
Proof of Concept / Prototype
Product Beta
Final Candidate / Commercialized
Concept / Thought / Idea
Proof of Concept / Prototype
Product Beta
Final Candidate / Commercialized
Other (please specify)
8.
What is your primary NAICS / SIC code?
NAICS
SIC
9.
How much financing has your company raised to date?
10.
What type of financing is your company looking for in the near future?
Seed Loan
Seed Equity
Series A Equity
Receivable or Inventory Financing
Federal or State R&D Funding (SBIR/STTR)
Other (please specify)